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HomeMy WebLinkAboutBuilding Permit # 9/1/2015 �a®RTIJ BUILDING PERMIT TOWN OF NORTHA OVER APPLICATION FOR PLAN EXAMINATION o p � p q n . Permit No##: b " Date Received �RQpRRTED pYpy tS wSs�cwusER Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Pint PROPERTY OWNER_ SA k 'f cA-K1 yo-1 (-A Print 100 Year Structure yes no MAP 62-5 PARCEL: ZONING DISTRICT:_ Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New BuildingOne family ❑Addition ❑ Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg rs: ❑ Demolition L1 Other ;K: DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly SiWNER: Name: r � Nk r,'A LA Phone: Address: Contractor Name: Phone: Email: Address: Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ mm Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund , - Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Flans ❑ TYPE OF SEWERAGE DISPOS Public Sewer S Tanning/Massage/Body Art ❑ wiunmin g Pools El Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ permanent Dwnpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - H FORM PLANNING & DEVELOPMENT Reviewed On � ( Signature44d,�_' COMMENTS � CONSERVATION Reviewed on I S Signature �b WO COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE-MPARTMENT - Temp.Dumpster on site yes no Located at 124,Main Street Firs Depa,rtmavnt signaiture/date COMMENTS Anb FORTH Andover own ot ? e ® � ® - h h Ver, MaSS9 LAKE 1. coc"ic"t-OrK S V BOARD OF HEALTH LD Food/Kitchen PERMIT Septic System BUILDING INSPECTOR THIS CERTIFIES THAT .�` ll..® ... ..I4,. Foundation buildings on .. .. ... ... ... has permission to erect g ��• •• Rough to be occupied as ......... ......................................................................... Chimney to be occupied as ........laxprovided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and PLUMBING INSPECTOR Construction of Buildings in the Town of North Andover. Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final ® ELECTRICAL INSPECTOR PERMIT EXPIRES I ® TS rRough UNLESS S TI AR Service .. .......I............................ Final BUILDING INSPECTOR GAS INSPECTOR ccupancy Permit squired t® Occupy Building Rough Final Display in a Conspicuous Place on the Premises — Do Not Remove FIRE DEPARTMENT No Lathing or Dry Wall To Be Done Burner Until Inspected and Approved by the Building Inspector. Street No. Smoke Det. NORTH TOWN OF NORTH ANDOVER pf tt�ev ,6;�"o OFFICE OF s BUILDING DEPARTMENT 1600 Osgood Street,Building 20, Suite 2035 4oRATIo�Tp``,`a North Andover,Massachusetts 01845 �SSACHUS�� Gerald A. Brown Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDING PERMIT APPLICATION Please print DATE: JOB LOCATION: c � r� G2 ocx p'Es`� vr 0 Number Street Address Map/Lot HOMEOWNER S"NOC CT SA rl KH CA 4 1 S 69 2-- 33 Name Home Phone Work Phone PRESENT MAILING ADDRESS City Town State Zip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.(780 CMR Section 110.R5.1.2) The undersigned"homeowner"assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE �►`�1 '` APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form Homeowners Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 i8 Commonwealth o,fMasff chusetts Department oflndlushlaZAceidents q' t M .. : F d Z Congress Street,Suite 100 ' Boston,MA 02114-2017 v 1-vww.mass.go-v7d1a sy. Workers'Compensation Insurance Affidavit:Buil.ders/Contractor°s/FXectricians/Plumbers. TO BE MED WITH TUE PERI4dMTTING AUTI(ORITY. A icant Information Please Print Legibly Namo(Busyness/Oxganizati-o-n— ndividual);, S-A Ntil;; I IN N K)i LA Address: Nl o b lk NAY 121 S '/`tet�A City/State/Zip: Phone##: -+ 6 c12_3 Are you an employer?Cb eck t&appropriate box. Type of project(fgquiz ed): 1,❑I am a employer with employees(full and/orpart time).* 7. []New construction 2, I am'a sole proprietor or partnership and have no employees Working for me in 8. [1 Remodeling any capacity.[No workers'comp.insurance required] g, U Demolition. S am a homeowner doing all work myself[No workers'comp.insurance required,]t 10 ❑Building addition 4.[]S am a homeowner andwill be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11. ]Electrical repairs or additions proprietors with no employees. 12.F]Plumbing repairs or additions 5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof 1 epair5 These sub-contractors have employees and have workers'comp,insruauce. 6.❑We are a corporation and its officers have exercised their light of exemption per MGL c• 14.[(Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any appHeantthat checks box41 must also fill out the section below showingtheirwarkers'compensationpolicy information. T Homeowners who subuutthis Adavit indicating they are doing all work andthen hire outside contractors must submit a new affidavit indicating such. ?Contractors that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. Nthe sub-c6n6c6s have employees,they n rust provide their workers'comp.policy number. I am an employer Mat ispioviding workers'compensation insurance for my employees,' Below is'the policy and lob site info oration, Insurance Company Name: Policy#or Self-ins,Lie.#: Expiration Date: Job Site Address; City/State/Zip: Attach,a.copy of the workers'coxnpensation.'policy declaration page(showing the p olicy number and expiration date). Failure to secure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a flue of up to$250.00 a day against the violator.A,copy of this statement may be forwarded to the Of}7ce of Investigations of the DIA for insurance coverage verification. fdoherebyeerdjyund the pazrrs andpenaltces ofperyuty that the information provided above is true and correct " °� Date' �C O 2—i7 1 Signature: �� Dt , Phone#: Official use only. )7o not write in this area,to be completed by city or town official City or Town: PelmitlLicense# Issuing Authority(circle one): i 1.Board of Health 2.BuildinglDepartm.ent 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6,Other Contact)Person: )Phone 4: riaW5< Mu V-1 4- I I •--- .�., ez 5. b 7 � nls/-/� A� 9� 5" O N r 9.20 ' ° �, ,�= Bio• 3,g! 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